CurrentHealth NetPolicy CP.MP.49

Physical, Occupational, and Speech Therapy Services

Criteria and authorization guidance for initial, continued, and reevaluation coverage of outpatient or home-based speech, occupational, and physical therapy services for Health Net members; applies to providers requesting authorization.

Policy Summary

PayerHealth Net

PolicyPhysical, Occupational, and Speech Therapy Services

Policy CodePolicy CP.MP.49

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain authorization for initial and continued outpatient or home therapy when criteria are met and submit a signed Plan of Care with required documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial, continued, reevaluation, discontinuationcriteria types covered

Speech eval in dominant languageexplicit requirement

Up to 6 monthsreeval frequency

≥1.5 SDscore threshold note

Coverage Criteria for Therapy Services

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Initial Authorization: Initial authorization is medically necessary when all listed criteria A–H are met

A: Clinical impairment: Signs and symptoms of physical deterioration or impairment in one or more of the following areas: sensory/motor ability; functional status evidenced by inability to perform basic activities of daily living (ADLs) and/or mobility; cognitive/psychological ability; cardiopulmonary status; or speech/language/swallowing and cognitive-communication disorders that result in disability.

B: Evaluation ordered and performed: Treatment is ordered by an examining physician or other qualified healthcare professional, and a formal evaluation is conducted by a licensed/registered speech, occupational, or physical therapist. The evaluation must include history, review of systems, physical assessment, current and previous level of functioning, tests/measurements of physical function, potential for improvement, treatment recommendations and patient/caregiver education; speech evaluations must be conducted in the member's dominant language.

C: Skilled need: Treatment requires the judgment, knowledge, and skills of a licensed/registered therapist or therapy assistant and cannot be reasonably learned and implemented by nonprofessional caregivers. Repetitive therapy drills that do not require a licensed/certified professional's feedback are not covered.

D: Standards and targeted intervention: Treatment meets accepted discipline-specific clinical practice standards and is targeted and effective for the diagnosed impairment or condition.

E: No duplication: Treatment does not duplicate services provided by other types of therapy or services provided in multiple settings.

F: Plan of Care requirements: A written Plan of Care (POC) signed by the therapist must include: diagnosis with date of onset/exacerbation; measurable short- and long-term functional goals specific to the condition; planned treatment techniques/interventions with amount, frequency, and duration; member/caregiver education and a home exercise program (HEP); prior treatment history; description of current level of functioning and comorbidities; most recent standardized evaluation scores (age equivalency, percent functional delay, or SD score) when appropriate; meaningful clinical observations and prognosis; and member agreement to participate.

Note: Standardized scores ≥ 1.5 SD below the mean may qualify but may not be used as the sole criterion.

G: Expected outcomes (one of): Treatment is expected to: 1) produce clinically significant and measurable improvement in functioning within a reasonable and medically predictable period, or 2) prevent significant functional regression as part of a medically necessary program, or 3) address likely loss/regression of function within a reasonable period.

Includes considerations for members under 21 (see policy).

H: Home treatment conditions: If treatment is provided in the home: 1) the treatment can be safely and adequately performed in the home environment; and 2) the diagnosed impairment or condition makes transportation to an outpatient rehabilitation facility impractical or medically inappropriate.

Continuation Therapy

Continued authorization is medically necessary when ALL of the following are met

Continued Authorization: At the end of each authorization period and when requesting additional visits, treatment progress must be clearly documented in an updated POC/current progress summary signed by the therapist and submitted by the requesting provider.

Documentation elements: Documentation must include: 1) updated standardized evaluation scores (age equivalency, percent functional delay, or SD score) if applicable; 2) objective measures of functional progress relative to each treatment goal with comparison to prior report; 3) summary of response to therapy and issues limiting progress; 4) documentation of member or caregiver participation in treatment; 5) documentation of participation/adherence with a HEP if applicable; 6) brief prognosis with clearly established discharge criteria; 7) explanation and clinical rationale for any significant POC changes; 8) prescribed treatment modalities with anticipated frequency and duration; 9) physician or other qualified healthcare professional signature on the POC or prescription; 10) if applicable for children, IFSP/IEP or attestation verifying no duplication of services.

Home treatment continued: If treatment is performed in the home: 1) the treatment can be safely and adequately performed in the home environment; and 2) the diagnosed impairment or condition makes transportation to an outpatient rehab facility impractical or medically inappropriate.

No Longer Medically Necessary

Services are no longer medically necessary when ANY of the following apply

Discontinue triggers: 1) Treatment goals have been achieved as evidenced by: no longer demonstrating functional impairment or achievement of POC goals; return to baseline function; continued management with a HEP; adaptation to impairment with assistive devices; or ability to perform ADLs with minimal to no caregiver assistance; 2) A functional plateau has been reached or additional therapy will no longer be beneficial; 3) Member is unable to participate in the POC due to medical, psychological, or social complications; 4) Non-compliance with a HEP and/or lack of participation in scheduled therapy appointments.

Note: Denial for failure to benefit or progress may be made when interventions per POC failed or maximum medical benefit achieved.

Reevaluation

Formal reevaluation is medically necessary up to once every six months when ALL of the following are met

Reevaluation: A formal reevaluation by a licensed/registered therapist is medically necessary up to once every six months when there is documentation of either: 1) new clinical findings or a significant change in condition not anticipated in the POC, or 2) failure to respond to therapeutic interventions outlined in the POC.up to once every 6 months

Reevaluation is not required solely to assess continued need unless one of the criteria is met.

Therapy is not medically necessary when one or more of the following apply: treatment goals have been achieved (e.g., no functional impairment, returned to baseline, continuing with a home exercise program, adapted with assistive devices, or able to perform ADLs with minimal/no caregiver assistance); a functional plateau is reached and additional therapy will not be beneficial; the member is unable to participate in the plan of care due to medical, psychological, or social complications; or there is non‑compliance with the home exercise program or failure to attend scheduled therapy appointments. A denial for failure to benefit may be made when maximum medical benefit has been achieved despite appropriate therapeutic interventions per the POC.

Authorization and Documentation Requirements

Prior Authorization

Prior authorization required when criteria met

Authorization required when criteria met — Initial and continued outpatient or home therapy require authorization when criteria are met. Initial authorization is dependent on documented signs/symptoms of impairment, a physician or qualified professional order, and a formal evaluation by a licensed/registered therapist. Continued authorization requires clear documentation of treatment progress in an updated Plan of Care (POC) or progress summary signed by the therapist at the end of each authorization period or when additional visits are requested.

Initial authorization: documented signs/symptoms, physician/qualified professional order, formal therapist evaluation, and POC meeting policy criteria.
Continued authorization: updated POC/progress summary signed by therapist with objective measures of progress, updated standardized scores (if applicable), participation documentation, home exercise program adherence, prognosis and discharge criteria.

Step Therapy

Step therapy

No step therapy program described for these services.

Documentation Required

Required documentation for authorization

A written Plan of Care (POC) signed by the therapist must be maintained and submitted for initial and continued authorization. The POC must include diagnosis/date of onset, measurable short- and long-term functional goals, planned treatment techniques with amount/frequency/duration, education for member and caregiver including HEP, history of prior treatment, current level of functioning and co-morbidities affecting benefit, most recent standardized evaluation scores when appropriate, meaningful clinical observations and prognosis, and member agreement to participate. For continued care, updated standardized scores, objective measures of functional progress versus prior report, summary of response and barriers to progress, documentation of participation or caregiver involvement, HEP adherence, revised POC rationale, prescribed modalities with anticipated frequency/duration, and physician or qualified professional signature must be provided. For children, IFSP/IEP or attestation verifying no duplication of services is required when applicable.

POC must be signed by the therapist and include: diagnosis and date of onset; specific, measurable short- and long-term functional goals; planned interventions with amount/frequency/duration; member/caregiver education and HEP; prior treatment history; description of current functioning and barriers; standardized evaluation scores (with age equivalency or SD when appropriate); clinical observations and prognosis; member agreement to POC.
Continued authorization documentation must include: updated standardized evaluation scores; objective measures of progress tied to goals; summary of response and limitations; documentation of member/caregiver participation; documentation of HEP adherence; brief prognosis with discharge criteria; explanation and rationale for any POC changes; prescribed modalities/frequency/duration; physician or qualified professional signature; IFSP/IEP or attestation for children when applicable.

Denial Risk

Common denial triggers

Common denial triggers — Denial risk when treatment consists of repetitive drills not requiring licensed professional feedback; when the request lacks a formal evaluation or an adequate POC; when treatment duplicates services in other settings; when there is no documented potential for improvement or measurable progress; when a functional plateau or achievement of goals is documented; when member is non‑compliant with HEP or therapy appointments; when POC lacks physician/qualified professional signature or required standardized scores where applicable.

Repetitive therapy drills without licensed/certified professional feedback are not covered.
Missing or incomplete POC (no diagnosis/date of onset, no measurable goals, missing planned interventions, or unsigned by therapist) may lead to denial.
Lack of documented progress, functional plateau, or failure to demonstrate potential for improvement may result in denial.
Duplication of services across settings or with other therapy types can be denied.
Non‑compliance with HEP or lack of participation in scheduled therapy sessions may lead to discontinuation of services.

Background

Physical and occupational therapy are therapeutic interventions designed to improve, develop, correct, or prevent worsening of physical functions and activities of daily living (ADLs) that have been lost or impaired due to acute or chronic conditions, congenital anomalies, or injury. Speech therapy addresses speech, language, communication, and swallowing disorders and should include evaluation in the member's dominant language when applicable. In the pediatric (EPSDT) context, medically necessary services are those ordered by an examining physician or qualified professional that diagnose, correct, or significantly ameliorate defects or conditions and that optimize health or prevent deterioration.

OpenPayer

Physical, Occupational, and Speech Therapy Services

Coverage Criteria for Therapy Services

Scoring and Coding Notes

Authorization and Documentation Requirements

Background

Definitions